26 May 2010

An idiom is a common expression that has acquired a meaning that differs from its literal meaning, such as “It's raining cats and dogs” or "kicked the bucket." Idioms can be very challenging for non-native speakers of a language to get their heads around, since there's often no relationship between the intent and the literal expression. My brother-in-law is an Israeli for whom English is his third language, and he and I have had many entertaining conversations about the colorful colloquialisms in the English language.

Recently, I was pretty upset about some clinical issue that was affecting care in the ER. I thought I might be over-reacting, which I am prone to from time to time, but I didn't want to back down from what I thought was an important matter. I went into our medical director's office and sat down. "OK, Larry," I began the conversation, "talk me off the ledge here..."

Which is a wonderful idiom, when you think about it. It's actually much more comprehensible than the "kicked the bucket" apocryphal sort, since it paints a vivid picture of a scenario familiar to anybody who has a passing familiarity with the "Lethal Weapon" movie series.

It became that much more ironic when, the next day, I was seeing a psychiatric patient in the ER. She was suicidal, but sort of chronically suicidal, the sort of depression-plus-personality-disorder patient who visits the ER more often than some staff but never actually does anything to harm herself.

As a digression, I have always thought that "personality disorder" is such a terrible diagnosis. I mean, if you're depressed or bipolar or whatever there are lots of hand-waving euphemisms such as "chemical imbalance" to allow patients to bolster their self-esteem and not feel like their illness is their fault. "Personality disorder" is so much worse -- it basically means that you're a fundamentally maladapted person and, so sorry, there's no pill we can give you that will fix that. How do you tactfully tell a patient something like that?

Anyway, this lady was a borderline personality type (all the medical professionals reading this just cringed) and she was driving us all nuts. Intermittently polite and charming alternated with shrieking and abusive behavior, and for a while she bought herself four-point restraints. No psych facility wanted to take her because they didn't see any benefit to hospitalization for this sort of chronic, not-serious suicidality. But she was demanding that we admit her somewhere, so we were kind of stuck.

Then she escaped.

This is not supposed to happen from the psych rooms in our ER. There's constant security presence and the doors lock. Obviously, somebody slipped up, which is easy enough to do when the patient is there for hours and hours. We didn't think she would be too difficult to find, though, since she had for some reason decided to strip naked before slipping out! Sure enough, she was spotted on the campus, running around, naked as a jaybird, and she let the police and security staff something of a merry chase before they finally corralled her in the parking garage.

But before they could cuff her, she ran up the stairs to the top of the garage. She climbed over the restraining barrier and out onto an I-beam which juts out about ten feet from the building, four stories up. There she stayed and refused to budge.

I have to complement the police on their management of this situation. They were consummate professionals in a difficult spot and they did manage to get her back in without her coming to any harm. She was returned to our department, wrapped in a thick blanket, wet and shivering. This time it was not difficult getting her placed at a psychiatric hospital.

At the end of my shift, I was dictating my charts. As I finished the dictation for this case, my partner who was coming on shift was sort of listening in as he did his paperwork. When I put down the phone, he turned to me and said, "I cannot tell you how jealous I am that you got to dictate in a medical record, the phrase 'talked off the ledge,' and it was literally true."

I agreed that it was remarkable, that sometimes the idioms really do come to life.

Our computer generated discharge info set up actually has decent instructions for personality disorder patients. They are kind of cruel and hilarious, but actually full of useful information. "Personality disorder is a way of saying that you have problems dealing with life's obstacles. It is not a true psychiatric illness. It won't get better until you decide to change"

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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